Evidence-based Practices in Drug and Alcohol Treatment and Recovery June 2016 Contents Introduction 2 Principles and goals of substance abuse treatment 4 Evaluation and determination of therapeutic service need 5 Withdrawal management services—management of acute intoxication and withdrawal 8 Alcohol 8 Benzodiazepines 9 Opioids 9 Medication-assisted therapies 9 Stimulants (cocaine and amphetamine) 10 Cannabis withdrawal 10 Hallucinogens (LSD, mescaline, psilocybin, and related drugs) 10 Phencyclidine (PCP) 11 Volatile substances (inhalants) 11 Club drugs 11 Designer drugs 11 Anabolic-androgenic steroids (AAS) 12 Interventions—substance abuse treatment and recovery 13 Psychosocial treatments 13 Somatic treatments (Psychopharmacotherapy) 14 Medication-assisted treatment (MAT) 15 Levels of care 18 Conclusion 19 References 20 ©2016 Magellan Health, Inc—Evidence-based Practices in Drug and Alcohol Treatment and Recovery 1 Introduction The use of illicit drugs, e g , marijuana, cocaine, physiological symptoms indicating that the heroin, hallucinogens, inhalants, and nonmedical individual continues using the substance despite use of prescription-type psychotherapeutic drugs, substance-related problems” (DSM-5, 2013) SUDs and alcohol is both a significant public health occur when recurrent use of the substance results problem and a challenge in the U S A national in a pathological pattern of related behaviors, e g , report, Behavioral Health Trends in the United impaired control and social impairment The 2014 States: Results from the 2014 National Survey NSDUH reported that approximately 21 5 million on Drug Use and Health (NSDUH), reported the people aged 12 and older in 2014 had SUDs in most recent statistical information on the use of the past year, including 7 1 million with an illicit substances by the U S population aged 12 years or drug use disorder, 17 million with an alcohol use older (SAMHSA, 2015) According to the NSDUH disorder, and 2 6 million with both an alcohol use report, in 2014, the percentage of people aged 12 disorder and an illicit drug disorder The NSDUH and older who used an illicit drug in the past 30 also reported that 4 2 million and 1 9 million people days was 10 2 percent, representing 27 million had past-year disorders related to marijuana use persons Notably, this percentage was higher than and nonmedical use of prescription pain relievers, the percentages in every year from 2002 through respectively Overall, the people who had SUDs in 2013 SAMHSA noted that this increase resulted 2014 represented 8 1 percent of the people aged 12 primarily from marijuana use and the nonmedical or older, similar to the percentages in 2011 – 2013 use of prescription pain relievers In 2014, the and lower than the percentages in 2002 to 2010 percentage of people aged 12 or older who were (SAMHSA, 2015) current marijuana users (8 4 percent) was greater than the percentages in 2002 to 2013, while the Published data from the National Institute on Drug percentage of people who were current nonmedical Abuse (NIDA) reported that prescription drug users of pain relievers (1 6 percent) was lower abuse is a significant problem in the U.S. (NIDA, than the percentages in most years from 2002 to 2015) The abuse and diversion of prescription 2012, although similar to the percentage in 2013 drugs is highest among young adults (age 18 to However, the percentage of people aged 12 or older 25) who use the drugs for various reasons, e g , to in 2014 who were current heroin users was higher produce euphoria, or they may believe stimulants than percentages in most years from 2002 – 2013 will improve academic performance In 2014, (SAMHSA, 2015) the percentages of various age groups using prescription drugs for nonmedical reasons in the The NSDUH reported that, in 2014, 66 9 million past year were as follows: 6 percent of 12-17 year- individuals (25 2 percent) aged 12 and older were olds; 12 percent of 18-25 year-olds; and 5 percent current users of tobacco products, and 139 7 million of persons 26 years or older (NIDA, 2015) The individuals (52 7 percent) were past month alcohol Centers for Disease Control and Prevention (CDC) drinkers Tobacco and cigarette use were lower indicated that the U S is experiencing an epidemic across all age groups in 2014 than in most years of drug overdose deaths, with more persons (47,055) from 2002 to 2013 Although in 2014 the percentage dying from drug overdoses in the U S in 2014 than of people aged 12 or older who were past-month during any previous year on record (CDC, 2015) alcohol users was approximately the same as in The main drugs associated with overdose deaths years 2009-2013, the report stated that binge alcohol are prescription pain relievers and heroin The rate use and heavy alcohol use among young adults, of opioid overdoses tripled from 2000 to 2014 and aged 18 to 25, was high at 37 7 percent and 10 8 in 2014, opioids were involved in 61 percent of all percent respectively (SAMHSA, 2015) drug overdose deaths Trends noted by the CDC are a 15-year increase in overdose deaths involving Substance use disorders (SUDs) are characterized prescription opioid pain relievers and the recent by “a cluster of cognitive, behavioral, and surge in illicit opioid overdose deaths, driven by 2 Evidence-based Practices in Drug and Alcohol Treatment and Recovery—©2016 Magellan Health, Inc heroin primarily The CDC discussed the need to To underscore the magnitude and complexity improve safer prescribing of prescription opioids of the problem related to substance use, it is (prescribing has quadrupled since 1999 increasing important to note that in 2014, 39 1 percent of the in parallel with overdoses) and emphasized the adults aged 18 or older with a past-year SUD also need to expand access to medication-assisted had a diagnosed co-occurring mental disorder treatment, in combination with behavioral therapies (SAMHSA, 2015) Among adults without a past year (CDC, 2015) A report by the National Council on SUD, only 16 2 percent had any diagnosed mental Alcohol and Drug Dependence (NCADD) reported disorder The percentage of adults with SUD and that more than 47,000 Americans died of a drug co-occurring mental disorder in 2014 was similar overdose in 2014, an increase of 7 percent from the to the percentages in most years from 2008 to previous year NCADD reported that the increase 2013 In 2014, 11 3 percent of the adults aged 18 or from 2013 to 2014 was driven largely by deaths older with a past-year SUD also had a diagnosed from heroin and prescription opioids Overdose serious mental illness (SMI), which was similar to deaths due to opioid painkillers (almost 19,000) the percentages of adults with SMI in most years and heroin increased by 16 percent and 28 percent, from 2008 to 2013 Additionally, among the adults respectively NCADD further reported that the rise with SMI in 2014, 23 percent also met the criteria in opioid-related deaths is due in part to synthetic for an SUD in the past year Moreover, “people with opioids, such as fentanyl (increasing the effect of a mental disorder are more likely to experience a heroin) (NCADD, 2016) substance use disorder and people with a substance use disorder are more likely to have a mental On March 22, 2016, the U S Food and Drug disorder when compared to the general population” Administration (FDA) announced a new black (SAMHSA, 2015) The National Survey of Substance box warning for immediate-release (IR) opioid Abuse Treatment Services (N-SSATS) reported that pain medication related to risk of misuse, abuse, approximately 45 percent of persons in the U S addiction, overdose and death (FDA, 2016) seeking treatment for SUD have been diagnosed as Additionally, the warning on IR opioid analgesics having a co-occurring mental and substance use includes a precaution about their use during disorder. This represents one of the most significant pregnancy As a part of the agency’s overall efforts problems facing the public mental health system to help reverse the prescription drug epidemic today In addition, the abuse of multiple substances and to inform prescribers about the importance is common and can complicate the assessment/ of balancing the serious risks of opioids with treatment of withdrawal syndromes, management their role in managing pain or when used for of associated medical conditions, and rehabilitation medication-assisted treatment, several additional efforts aimed at relapse prevention and recovery safety labeling changes across all prescription (SAMHSA, 2015) opioid products (both extended release [ER] and IR products) are now required Substance abuse treatment providers utilize comprehensive/high-quality screening tools, A recent study described trends in benzodiazepine clinical practice guidelines, treatment protocols prescriptions and related overdose mortality and placement criteria developed and published (Bachhuber et al , 2016) Authors reported that by professional associations/government agencies, the number of adults filling a benzodiazepine e g , American Psychiatric Association (APA), prescription increased 67 percent between American Society of Addiction Medicine (ASAM), 1996 and 2013; the percentage of adults filling U S Department of Health and Human Services, a benzodiazepine prescription increased 4 1 Substance Abuse and Mental Health Services percent to 5.6 percent; and the total quantity filled Administration (SAMHSA), National Institute on more than tripled However, the rate of overdose Drug Abuse (NIDA) and others These represent mortality involving